Stent or bypass surgery for coronary artery disease?

An international study in this week's issue of The Lancet highlights how patients given bypass surgery for blocked or narrowed coronary arteries are less likely to require further intervention than patients given stent-assisted balloon angioplasty. The study also reported an apparent survival benefit for patients given bypass surgery over those given angioplasty.

Results of previous trials comparing coronary angioplasty with coronary artery bypass grafting (CABG) suggest that rates of death or heart attack do not differ between treatment strategies. However, coronary angioplasty is associated with an increased likelihood of the need for additional revascularisation (another, unplanned repeat procedure). The use of stents in addition to balloon angioplasty should reduce the need for additional revascularisation; the aim of the Stent or Surgery (SoS) trial, led by Rodney Stables from the Cardiothoracic Centre, Liverpool, UK, was to compare the effect of stent-assisted coronary angioplasty with CABG.

1000 patients with coronary artery disease from 53 centres in Europe and Canada were randomly assigned to treatment with stent-assisted angioplasty or CABG. After an average two-year follow-up, around 20% of patients given stenting required additional revascularisation compared with only 6% of patients given CABG. Overall, there was a reduction in subsequent heart attack among patients given angioplasty (5%) than those given CABG (8%). There were fewer deaths among patients given CABG (2%) than those given angioplasty (5%).

Rodney Stables comments: "The use of coronary stents has reduced the need for repeat revascularisation when compared with previous studies that used balloon angioplasty, though the rate remains significantly higher that in patients managed with CABG. The apparent reduction in mortality with CABG requires further investigation."

In an accompanying Commentary (p 961), William O'Neill and Cindy Grines from William Beaumont Hospital, Michigan, USA, state how the advent of drug-eluting stents is going to strengthen the case for angioplasty as an alternative to bypass surgery for the treatment of coronary artery disease. They conclude: "Surgery is likely to remain as the preferred choice for complex anatomical subsets. As the safety and durability of angioplasty continues to improve, the gap in choices will continue to narrow."

Contact: Dr Rodney H Stables, The Cardiothoracic Centre Liverpool,
Thomas Drive,
Liverpool,L14 3PE;UK;
T) 44-151-293-2489;
F) 44-151-293-2254;
E) r.stables@btinternet.com

Dr William O'Neill, Division of Cardiology, Department of Internal Medicine,
William Beaumont Hospital,
Royal Oak, MI 48073, USA ;
T) 248-551-4198;
F) 248-551-2526;
E) woneill@smtpgw.beaumont.edu

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